The Impact of Clinical Social Franchising on Health Services in Low- and Middle-Income Countries: A Systematic Review

Abstract

BackgroundThe private sector plays a large role in health services delivery in low- and middle-income countries; yet significant gaps remain in the quality and accessibility of private sector services. Clinical social franchising, which applies the commercial franchising model to achieve social goals and improve health care, is increasingly used in developing countries to respond to these limitations. Despite the growth of this approach, limited evidence documents the effect of social franchising on improving health care quality and access.Objectives and MethodsWe examined peer-reviewed and grey literature to evaluate the effect of social franchising on health care quality, equity, cost-effectiveness, and health outcomes. We included all studies of clinical social franchise programs located in low- and middle-income countries. We assessed study bias using the WHO-Johns Hopkins Rigour Scale and used narrative synthesis to evaluate the findings.ResultsOf 113 identified articles, 23 were included in this review; these evaluated a small sample of franchises globally and focused on reproductive health franchises. Results varied widely across outcomes and programs. Social franchising was positively associated with increased client volume and client satisfaction. The findings on health care utilization and health impact were mixed; some studies find that franchises significantly outperform other models of health care, while others show franchises are equivalent to or worse than other private or public clinics. In two areas, cost-effectiveness and equity, social franchises were generally found to have poorer outcomes.ConclusionsOur review indicates that social franchising may strengthen some elements of private sector health care. However, gaps in the evidence remain. Additional research should include: further documentation of the effect of social franchising, evaluating the equity and cost-effectiveness of this intervention, and assessing the role of franchising within the context of the greater healthcare delivery system.

Program Impact Pathway Analysis of a Social Franchise Model Shows Potential to Improve Infant and Young Child Feeding Practices in Vietnam

“…Social franchising is an innovative approach to improving access to and quality of health care services, particularly in low-and middle-income countries (1,2). It applies commercial franchising concepts so that a brand identity is equated with quality services that help achieve social and health benefits.…”

“…However, a growing body of research on social franchising interventions shows mixed results across a variety of outcomes (1,(6)(7)(8). Social franchising is associated with improvements in patient-reported quality-of-care indicators such as client satisfaction (9)(10)(11).…”

“…Social franchising is associated with improvements in patient-reported quality-of-care indicators such as client satisfaction (9)(10)(11). However, there is a paucity of studies that comprehensively assess quality of care across multiple dimensions such as provider practice, provider knowledge and skills, and service availability (1,6). In addition, the evidence related to improvements in health care utilization is mixed (1,6).…”

“…However, there is a paucity of studies that comprehensively assess quality of care across multiple dimensions such as provider practice, provider knowledge and skills, and service availability (1,6). In addition, the evidence related to improvements in health care utilization is mixed (1,6). Impacts on health knowledge and behaviors have been documented among individual franchise clients (12)(13)(14), but there is little evidence of impact on populationlevel health behaviors and outcomes (1).…”

“…In addition, the evidence related to improvements in health care utilization is mixed (1,6). Impacts on health knowledge and behaviors have been documented among individual franchise clients (12)(13)(14), but there is little evidence of impact on populationlevel health behaviors and outcomes (1). In a previous study, we documented changes in quality of care at the franchisee level (15); in this article, we expand on previous research by using new data and documenting the impact pathways all the way to infant and young child feeding (IYCF) practices.…”